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What Is A Nursing Care Plan and Why is it Needed?

In nursing school, there is probably no more hated class assignment than the nursing care plan. They’re assigned for every type of class, for intensive care patients, in mental health, and even for community care. Nursing students stay up all night preparing patient-specific care plans for the next day’s clinical, but why is this agony inducing tool still used so universally?

Continuity of care. The care plan is a means of communicating and organizing the actions of a constantly changing nursing staff. As the patient’s needs are attended to, the updated plan is passed on to the nursing staff at shift change and during nursing rounds.

Care plans help teach documentation. The care plan should specifically outline which observations to make, what nursing actions to carry out, and what instructions the client or family members require.

They serve as a guide for assigning staff to care for the client. There may be aspects of the patient’s care that need to be assigned to team members with specific skills.

Care plans serve as a guide for reimbursement. Medicare and Medicaid originally set the plan in action, and other third-party insurers followed suit. The medical record is used by the insurance companies to determine what they will pay in relation to the hospital care received by the client. If nursing care is not documented precisely in the care plan, there is no proof the care was provided. Insurers will not pay for what is not documented.

The purpose of students creating care plans is to assist them in pulling information from many different scientific disciplines as they learn to think critically and use the nursing process to problem solve. As a nursing student writes more plans, the skills for thinking and processing information like a professional nurse become more effectively ingrained in their practice.

Care Plan Formats

The exact format for a nursing care plan varies slightly from place to place. They are generally organized by four categories: nursing diagnoses or problem list; goals and outcome criteria; nursing orders; and evaluation.

As defined by the the North American Nursing Diagnosis Organization-International (NANDA-I), nursing diagnoses are clinical judgments about actual or potential individual, family or community experiences or responses to health problems or life processes. A nursing diagnosis is used to define the right plan of care for the client and drives interventions and patient outcomes.

Nursing diagnoses also provide a standard nomenclature for use in the Electronic Medical Record (EMR), allowing for clear communication among care team members and the collection of data for continuous improvement in patient care.

Nursing diagnoses differ from medical diagnoses. A medical diagnosis — which refers to a disease process — is made by a physician and will be a condition that only a doctor can treat. In contrast, a nursing diagnosis describes a client’s physical, sociocultural, psychologic and spiritual response to an illness or potential health problem. For as long as a disease is present, the medical diagnosis never changes, but a nursing diagnosis evolves as the client’s responses change.

The goal as established in a nursing care plan — in terms of observable client responses — is what the nurse hopes to achieve by implementing nursing orders. It is a desired outcome or change in the client’s condition. The terms goal and outcome are often used interchangeably, but in some nursing literature, a goal is thought of as a more general statement while the outcome is more specific. For example, a goal might be that a patient’s nutritional status will improve overall, while the outcome would be that the patient will gain five pounds by a certain date.

Nursing orders are instructions for the specific activities that will perform to help the patient achieve the health care goal. How detailed the order is depends on the health personnel who will carry out the order. Nursing orders will all contain:

A content area that is the where and the what of the order, for example, placing a “spiral bandage on the left leg from ankle to just below the knee”

A time element will define how long or how often the nursing action will occur

The signature of the prescribing nurse, since orders are legal documents.

Finally, in the evaluation, the client’s health care professionals will determine the progress towards the goal achievement and the effectiveness of the nursing care plan. The evaluation is extremely important because it determines if the nursing interventions should be terminated, continued or changed.

To help students learn and apply their knowledge, educators often add one more category to care plans. The rationale is the scientific reason for selecting a specific nursing action. Students may be required to cite supporting literature for their plan and rationale.

Care plans teach nursing students how to think critically, how to care for patients on a more personal level, not as a disease or diagnosis. They help teach how to prioritize care and interventions. They are a necessary evil of nursing school, tried and true for teaching future nurses not to care, but how to provide care that will improve the client’s health status.